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Identifying Medical Record Components – a Crucial Process in Medical Record Review

Identifying the components in the medical record is an important part of the medical record review process. The major components professional medical reviewers look for in a patient’s medical record include:

  • Patient registration form or patient identification
  • Consent for treatment; consent for invasive procedures (if relevant)
  • Lifetime authorization for Medicare (if relevant)
  • Benefit assignment and release of information
  • Medical history of the patient including drug allergies if any
  • Medication sheet
  • List showing problems
  • Preventive medicine screenings
  • Encounter notes
  • Diagnostic and therapeutic notes
  • Clinical notes such as progress notes, consultation reports, nursing notes and entries by particular personnel
  • Laboratory reports and procedural reports
  • Discharge notes including final disposition, condition at discharge, prescribed medications and follow-up instructions
  • Primary care (preventive medicine) services
  • Immunization records

Medical reviewers will organize all the records, and extract the required data from them. They will also identify any inconsistency in the records. Expert medical record review involves checking whether the entries are accurately dated and authenticated by the provider – whether physician, nurse, nurse practitioner, medical assistant and other healthcare providers who have access to the medical records.

When preparing the summary based on the medical records, the reviewer will focus on specific issues of the case such as the injuries alleged by the claimant, and what claims are being made. The summary is prepared in a chronological order, even if the medical records are not available in an organized manner. Summaries can be narrative or chronological. In the narrative summary, the extracted information is paraphrased and placed in an easily readable layout. This kind of summary contains only the crucial data and can be included as such in trial briefs, arbitration/mediation briefs, and demand letters. It can be more detailed depending on the attorney’s requirements. In the chronological summary, the important medical events and treatments are placed in chronological order within the summary. The data provided can be comprehensive or brief according to the attorney’s needs. Chronological summaries can be used when preparing for trial/deposition or when drafting demand letters.

The final document provided to the physician/attorney/paralegal will be thoroughly readable and orderly, facilitating trial preparation and decision making.

About Julie Clements

Julie Clements

With some background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort; Julie joined MOS in March of 2008. Hired for sales and support, Julie has proven capable across multiple product lines and in early 2011 was promoted to supervise all solutions managers.